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Quality and Patient Safety

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Quality and Patient Safety Handoffs Emily Carr Collaboration Project * To Err is Human/IOM Report Estimated that 44,000 to 98,000 Americans die each year as a result ... – PowerPoint PPT presentation

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Title: Quality and Patient Safety


1
Quality and Patient Safety
  • Handoffs
  • Emily Carr Collaboration Project

2
How Hazardous is Healthcare?
Dangerous (gt1/1000)
Regulated
Ultra-safe (lt1/100K)
100,000
Health Care
Driving
10,000
Total Lives Lost per year
1,000
Scheduled Airlines
Chartered Flights
Mountain Climbing
100
European Railways
Bungee Jumping
Chemical Manufacturing
10
Nuclear Power
100,000
1,000,000
10
1
10,000
10,000,000
100
1,000
Number of encounters for each fatality
3
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4
To Err is Human/IOM Report
  • Estimated that 44,000 to 98,000 Americans die
    each year as a result of adverse events.
  • Adverse events result from system error rather
    than poor performance or purposefully harmful
    individuals.(Sharpe, 2003)

5
CIHI Report -2004
  • Canadian National Study that analyzed 3745 charts
  • 7.5 hospitalized patients experience an adverse
    event
  • 2/3 AE resulted in temp. disability and the other
    1/3 were more serious even deaths.
  • Potentially 9,000-24,000 deaths annually due to
    adverse events.

6
1 Error Rate (American Stats)
  • 3 jumbo jet crashes every 2 days
  • 16,000 pieces of lost mail every hour

7
1 Error Rate
  • 32,000 bank cheques deducted from the wrong
    account every hour.
  • If we accepted 0.1 that would mean
  • 99.9 2 unsafe landings at OHare daily.
    (Deming 1987)

8
Steps to Improve Safety
  • Basic Tenets of Human Error
  • Everyone commits errors
  • Human error is generally the result of
    circumstances that are beyond the conscious
    control of those committing the errors
  • Systems or processes that depend on perfect human
    performance are fatally flawed
    Brown-Spath

9
Process Redesign Solutions
  • Design safer processes
  • Barriers or safeguards can prevent untoward
    events
  • X-ray confirmation of tube placement
  • Mandatory repeat-backs (Starbucks)
  • Door alarms
  • Surgical site confirmation
  • Brown-Spath

10
The System in Action
133 People to take care of the Patient
The Patient
The Safer Patient Initiative, North Wales, UK
11
Some Examples
12
Human Factors
13
Medication Safety
  • Illegible Handwriting
  • Look Alike/Sound Alike (Cerebrex, Celebrex)
  • Unsafe Abbreviations
  • Unsafe High-Risk Medications
  • Verbal Order Read Back (Starbucks!)

14
Packaging
15
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16
Communication
  • Some examples of strategies are
  • Surgical Safety Checklist
  • SBAR
  • Handoffs
  • Shift Reports

17
Safety Checklists
  • Communication tools to empower teams by
    increasing situational awareness, teamwork and
    cooperation, problem-solving and decision-making,
    and leadership and management in complex
    environments
  • Many industries
  • Aviation and Aerospace,
  • Energy (hydro, nuclear, petro-chemical),
  • Heavy Construction
  • Military

18
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19
Surgical Team in Action
20
SBAR
  • Situation what is the problem?
  • Background pertinent information to problem at
    hand
  • Assessment clinical staffs assessment
  • Recommendation what do you want done and/or
    think needs to be done? (hardest for RNs to do)

21
What do we mean by handoffs?
  • Situations where information is passed from one
    caregiver to another
  • Between individuals, teams, departments
  • Different times of day and varying situations

22
Shift Reports
  • Reports between nurses at shift change
  • Variety of different methods
  • Tapes, verbal, written notes, etc.

23
Some examples
  • Youtube http//www.youtube.com/watch?vzw5cy8yoE
    bsfeaturerelated
  • http//www.youtube.com/watch?vN-Xy-gbVbXkfeature
    related
  • http//www.youtube.com/watch?vcyOAEcMgo3cfeature
    related
  • http//www.youtube.com/watch?ve0mYe14UbVAfeature
    related
  • http//www.youtube.com/watch?vNOKDrWyYM6Ifeature
    related

24
Your Challenge
  • Design an innovative strategy to improve
    shift-to-shift report for a variety of different
    nursing areas that
  • Improves communication
  • Efficient
  • Timely
  • Incorporates appropriate information to safety
    hand patient over to next shift

25
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